Evaluation and Management Coding Advisor

1 Evaluation and ManagementCoding Advisor2017 2016 Optum360, LLCCPT 2016 American Medical Association. All Rights Reserved. iContentsChapter 1: Introduction .. 1 Origin And Development Of Evaluation And Management Codes .. 1 Physician or Other Qualified Health Care Professional .. 5 Contents .. 6 How to Use Evaluation and Management Coding 8 Knowledge Assessment .. 11 Chapter 2: The Building Blocks of E/M Coding .. 13 Levels of E/M Services .. 13 Component Sequence and Code Selection .. 14 Key Components .. 17 Contributory Components .. 35 Modifiers Used with E/M Codes .. 38 Selecting an E/M Code .. 39 Knowledge Assessment .. 40 Chapter 3: The Elements of Medical Documentation .. 43 Principles of Documentation .. 44 Evaluating Your Documentation .. 45 The SOAP Format .. 45 The SNOCAMP Format .. 46 Audit Considerations in Documentation .. 48 Over-Documenting the Encounter .. 49 Knowledge Assessment .. 52 Chapter 4: Adjudication of Claims by Third-Party Payers and Medicare.

2 55 Medically Necessary Services .. 55 Documentation Policy Under the Medicare Program .. 59 Teaching Physician Documentation .. 60 Incident-to 66 Physician Quality Reporting System .. 71 Comprehensive Error Rate Testing (CERT) 72 Knowledge Assessment .. 75 Chapter 5: Office or Other Outpatient Services (99201 99215) .. 77 New Patient (99201 99205) .. 77 Quick Comparison .. 77 General Guidelines .. 77 Issues in This Code Range .. 79 Special 79 Established Patient (99211 99215) .. 93 Quick Comparison .. 93 General Guidelines .. 93 Issues in This Code Range .. 95 Chapter 6: Hospital Services (99217 99239) .. 109 Initial Hospital Observation and Discharge Services (99217 99220) .. 109 Quick Comparison .. 109 General Guidelines .. 109 Issues in This Code Range .. 111 Subsequent Hospital Observation Services (99224 99226) .. 120 Quick Comparison .. 120 General Guidelines .. 120 Issues in This Code Range .. 121 Initial Hospital Care (99221 99223).

3 128 Quick Comparison .. 128 General Guidelines .. 128 Issues in This Code Range .. 129 Subsequent Hospital Care and Hospital Discharge Services (99231 99239) .. 138 Quick Comparison .. 138 General Guidelines .. 138 Issues in This Code Range .. 140 Chapter 7: Consultations (99241 99255) .. 153 Office or Other Outpatient Consultations (99241 99245) .. 153 Quick Comparison .. 153 General Guidelines .. 153 Inpatient Consultations (99251 99255) .. 168 Quick Comparison .. 168 General Guidelines .. 168 Telehealth ED or Initial Inpatient Consultation Services (G0425-G0427) .. 182 Quick Comparison .. 182 General Guidelines .. 182 Telehealth Follow-up Inpatient Consultation Services (G0406-G0408) .. 186 Quick Comparison .. 186 General Guidelines .. 186 Chapter 8: Other Hospital Based Services (99281 99292) .. 189 Emergency Department Services, New or Established Patient (99281 99288) .. 189 Quick Comparison .. 189 General Guidelines .. 190 Issues in This Code Range.

4 191 Evaluation and Management Coding Advisorii 2016 Optum360, LLC CPT 2016 American Medical Association. All Rights Reserved. Critical Care Services (99291 99292) .. 205 Quick Comparison .. 205 General Guidelines .. 205 Chapter 9: Residential Care Services (99304 99340) .. 211 Nursing Facility Services (99304 99318) .. 211 Initial Nursing Facility Care (99304 99306) .. 211 Quick Comparison .. 211 General Guidelines .. 211 Issues in This Code Range .. 212 Subsequent Nursing Facility Care, Discharge, and Annual Nursing Assessment (99307 99318) .. 221 Quick Comparison .. 221 General Guidelines .. 221 Issues in This Code Range .. 222 Domiciliary, Rest Home, or Custodial Care Services New Patient (99324 99328) .. 230 Quick Comparison .. 230 General Guidelines .. 230 Domiciliary, Rest Home, or Custodial Care Services Established Patient (99334 99337) .. 237 Quick Comparison .. 237 General Guidelines .. 237 Domiciliary, Rest Home ( , Assisted Living Facility), or Home Care Plan Oversight Services (99339 99340).

5 243 Quick Comparison .. 243 General Guidelines .. 243 Chapter 10: Home Services (99341 99350) .. 245 New Patient (99341 99345) .. 245 Quick Comparison .. 245 General Guidelines .. 245 Established Patient (99347 99350) .. 252 Quick Comparison .. 252 General Guidelines .. 252 Issues in This Code Range .. 253 Chapter 11: Prolonged Physician Services (99354 99359) .. 259 Prolonged Service with Direct Patient Contact (99354 99357) .. 259 Quick Comparison .. 259 General Guidelines .. 259 Special Instructions for Prolonged Physicians Services .. 259 Prolonged Service Without Direct Patient Contact (99358 99359) .. 264 Quick Comparison .. 264 General Guidelines .. 264 Chapter 12: Other E/M Services (99363 99456) .. 267 Anticoagulant Management (99363 99364) ..267 Quick Comparison .. 267 General Guidelines .. 267 Medical Team Conferences (99366-99368) ..269 Quick Comparison .. 269 General 269 Care Plan Oversight Services (99374 99380) ..270 Quick Comparison.

6 270 General Guidelines .. 272 Preventive Medicine Services (99381 99429) ..275 Quick Comparison .. 275 General Guidelines .. 276 Issues in These Code Ranges .. 277 Initial Preventive Physical Exam and Annual Wellness 277 Non-Face-to-Face Physician Services (99441 99444) ..281 Quick Comparison .. 281 General 281 Interprofessional Telephone/Internet Consultations (99446 99449) ..282 Quick Comparison .. 282 General 282 Special Evaluation and Management Services (99450 99456) ..284 Quick Comparison .. 284 General 284 Issues in This Code Range .. 285 Chapter 13: Newborn and Pediatric Services (99460 99486) .. 287 Newborn Care Services (99460 99465) ..287 Quick Comparison .. 287 General 287 Issues in This Code Range .. 287 Critical Care Pediatric Patient Transport (99466 99467, and 99485 99486) ..288 Quick Comparison .. 288 General 288 Neonatal and Pediatric Inpatient Critical Care (99468 99476) ..291 Quick Comparison .. 291 General 291 Intensive Critical Care Initial and Continuing (99477 99480).

7 294 Quick Comparison .. 294 General 294 Chapter 14: Care Management Services (99487 99490) .. 295 Quick 295 General Guidelines .. 295 Contents 2016 Optum360, LLCCPT 2016 American Medical Association. All Rights Reserved. iiiChapter 15: Transitional Care Management Services (99495 99496) .. 299 Quick Comparison .. 299 General Guidelines .. 299 Chapter 16: Advance Care Planning .. 303 Quick Comparison .. 303 General Guidelines .. 303 Chapter 17: Electronic Health Records .. 305 Introduction .. 305 Defining an EHR .. 305 Health Information Technology for Economic and Clinical Health (HITECH) Act .. 309 Meaningful Use .. 313 Certified Suppliers .. 322 EHR Documentation of 323 Electronic Health Record 324 Sample 328 EHR Encoders .. 329 Brief Review of Evaluation and Management Coding .. 329 Post-Implementation .. 331 Coding Changes .. 332 Education .. 333 Data Capture .. 334 Summary .. 334 Knowledge Assessment .. 335 Chapter 18: Knowledge Assessments with Answers.

8 339 Chapter 1 Questions and 339 Chapter 2 Questions and 340 Chapter 3 Questions and 343 Chapter 4 Questions and 344 Chapter 17 Questions and 347 Glossary .. 351 Appendix A: Physician E/M Code Self-Audit Forms .. 365 Appendix B: Crosswalk for 1995 and 1997 E/M Documentation Guidelines .. 379 Appendix C: 1995 Evaluation and Management Documentation Guidelines .. 393 Appendix D: 1997 Evaluation and Management Documentation Guidelines .. 405 Index .. 433 Evaluation amd Management Coding Advisor84 2016 Optum360, LLC CPT 2016 American Medical Association. All Rights REQUIREMENTSM edical Decision Making: low Limited number of diagnoses or Management options considered Limited amount and complexity of data reviewed Low risk of complications or morbidity or mortalityProblem Severity: moderate Moderate risk of morbidity without treatment Moderate risk of mortality without treatment Uncertain outcome or increased probability of prolonged functionalimpairment or increased probability of prolonged functionalimpairmentHistory: detailed Chief complaint Extended history of present illness (four or more HPI elements or thestatus of three chronic problems) Extended system review (two to nine systems) Pertinent past, family, and/or social history (one of the history areas)Examination: detailed 1995: two to seven organ systems or body areas with an extended examof affected area(s) 1997.

9 At least two bullet ( ) elements from at least six organ systems orbody areas, OR at least 12 bullet ( ) elements from two or more organ systems or body areas. Eye and psychiatric single-system exams must include at least nine bullet ( ) Indicators (from tables of risk including some AMA indicators in italic) Presenting Problem(s) Two or more self-limited or minor problem(s) One stable chronic illness ( , well controlled hypertension ornon-insulin-dependent diabetes, cataract, BPH) Acute uncomplicated illness or injury ( , cystitis, allergic rhinitis,simple sprain) Management Options Physical therapy, rest or exercise, diet, stress Management Over the counter drugs, medication Management with minimal risk Minor surgery, with no identified risk factors Occupational therapy IV fluids, without additivesCounseling and/or coordination of care As appropriate for the problemTime Spent Face to Face (average) 30 minutesChapter 5: Office or Other Outpatient Services (99201 99215) 2016 Optum360, LLCCPT 2016 American Medical Association.

10 All Rights Documentation 99203 Level III Initial Office Visit Reason for visit: Something is really wrong HPI: This 18-year-old white female complains of vaginal itching, burning, and pain for three days, getting worse and worse. She tried an OTC preparation, but it provided little relief. She has never had a GYN exam before and is apprehensive. She has been sexually active for three years, has had four partners and always uses condoms for protection. Past history unremarkable. She denies use of tobacco, drugs, or alcohol except for a beer or two on weekends. She is a university student, lives in the dorms, works part time at the university. No known allergies. Menses regular, lasting three to four days, normal flow; LMP 10 days ago. No history of STD or previous GU infections. Review of systems otherwise within normal limits. Physical exam: Vital signs: T: , R: 18, P: 76, BP: 116/78. Abdomen: no organomegaly, no masses or tenderness. External genitalia, red and irritated with a foul-smelling creamy discharge oozing from the vagina; no lesions noted.